Cases & Commentaries

Crossing the Borderline

Commentary By John M. Oldham, MD

The Case

A 24-year-old woman with borderline personality
disorder was admitted to an inpatient psychiatry unit following a
failed suicide attempt with excess doses of acetaminophen. The
patient had a history of suicide attempts, including episodes of
self-inflicted trauma and abusive behavior. Upon admission, the
patient was isolative, displaying a flat affect and expressing a
desire to harm herself. When her mood significantly improved after
several days of restricted activities, the care team provided her
with more freedom, hoping it would improve her condition. Despite
occasional gestures suggesting ongoing risk for self-harm as well
as continued conflicts with the care team, the patient’s
behavior became focused on a home visit for her upcoming
birthday.

As the care team had observed nearly 72 hours of
appropriate behavior, the day before her birthday, they granted
permission for the patient’s request. Later that evening at
home, the patient set herself on fire, prompting immediate return
to the hospital for necessary treatment. The events prompted a
review and a strengthening of the policies regarding formal risk
assessment in this patient population.

The Commentary

Borderline Personality Disorder (BPD) is a
disorder with an age of onset between 18 and 25.(1) It is categorized in the dramatic/emotional/impulsive
cluster of personality disorders; diagnosis is made when five of
nine DSM-IV-TR (2)
criteria are met (Table), and the prototypic patient with BPD shows a
pervasive pattern of instability of mood, impulse control,
interpersonal relationships, and self-image. The prevalence of BPD
is estimated to be between 1% and 2% in the general population
(3), 6%
in a primary care population (4),
and between 10% and 20% of psychiatric outpatient and 15% and 20%
of psychiatric inpatient populations.(5) Common comorbidities include mood disorders, anxiety
disorders, eating disorders, substance use disorders, other
personality disorders, and a range of medical disorders.(5)
Patients with BPD generally experience high levels of dysphoria and
psychic pain (6),
usually in the context of interpersonal distress. Some patients
electively seek help from a psychiatrist or primary care physician,
and they complain of anxiety, depression, or suicidality. Others,
feeling distressed by real or perceived maltreatment or rejection
by others, may attempt suicide or behave in other self-injurious
ways, leading to emergency intervention. Careful history taking
often reveals a pattern of emotional and behavioral dysregulation
prior to initiation of treatment, not uncommonly accompanied by a
history of trauma, abuse, or neglect early in life.(1)

“Recurrent suicidal behavior, gestures, or
threats or self-mutilating behavior” is one of the DSM-IV-TR
diagnostic criteria for BPD, and self-injurious behavior has been
referred to as the borderline patient’s “behavioral
specialty.”(7)
Deliberate self-harm includes suicide attempts (intentionally
self-destructive acts accompanied by at least a partial intent to
die) and non-suicidal self-harm (intentional self-destructive
behavior with no intent to die).(8) It
is estimated that as many as 75% of patients with BPD make at least
one non-lethal suicide attempt (8),
and the rate of actual suicide in patients with BPD is between 8%
and 10%.(9,10)
Risk factors for suicidal behavior in patients with BPD include
prior suicide attempts, family history of suicidal behavior,
history of sexual abuse, high levels of hopelessness, co-morbid
mood disorders and substance use disorders, and high levels of
impulsivity and/or antisocial traits.(9)

The American Psychiatric Association Practice
Guideline for the Treatment of Patients with Borderline Personality
Disorder (5)
provides an evidence-based recommendation for psychotherapy as the
primary, or core, treatment of patients with BPD, accompanied by
symptom-targeted adjunctive pharmacotherapy. In most cases, the
psychotherapy, whether cognitive-behavioral or psychodynamic, is
carried out in an outpatient or partial hospital setting and
involves weekly treatment for a year or more. The priority
treatment goal that characterizes the early phase of psychotherapy
is to help the patient learn to reduce self-harming and suicidal
behavior. A common error in treatment of patients with BPD is to
underestimate the importance of self-injurious behavior or to view
suicidal ideation as only likely to lead to non-lethal suicide
“gestures.” The largely heritable endophenotypes that
underlie this behavior are thought to be impulsive aggression and
affect dysregulation (11),
and it is often interpersonal stress that precipitates
affect-laden, impulsive self-harming behavior.

In the case presented here, the patient had known
risk factors of former suicide attempts and self-inflicted trauma.
It is not clear what precipitated the unsuccessful suicide attempt
that led to the current hospitalization, but clarifying the
interpersonal circumstances that were occurring in her life prior
to the suicide attempt would be crucial. Patients with BPD
frequently demonstrate mood shifts, and this patient, in the
structured setting of the hospital, shed her dysphoria and
requested a home visit for her birthday. Who was at home? What was
the nature of the patient’s relationships with those at home?
What have previous birthday celebrations been like? Since family
stress and interpersonal conflicts are so common for patients with
BPD, birthdays are often formulas for disappointment. In this case,
perhaps all signals were green and the self-injury on the home
visit could not have been anticipated. However, given the modal
pattern of disturbed family and interpersonal relationships for
patients with BPD, it seems far more likely that the
patient’s expectation of a positive home visit on her
birthday represented an idealized fantasy. Patients with BPD can
become angry and oppositional when challenged, and the staff may
have supported the patient’s request partially, at least, to
prevent a regressive eruption of rage and the possibility of
reactivated self-injurious behavior in the hospital.

Clinicians often feel conflicted about management
decisions such as this one when working with patients with BPD.
There is controversy about the role of the hospital, particularly
regarding its therapeutic usefulness for self-injurious behavior in
borderline patients.(12)
However, hospitalization may be essential at times of extreme
suicide risk, such as that in the case presented here. Evaluation
tools to assess degree of suicide risk, such as the Suicide
Behaviors Questionnaire (revised) (13) or
the Suicidal Ideation and Risk Level Assessment (14), are generally applicable for patients with major
depressive disorder or bipolar disorder, and these may be useful to
guide treatment of patients with BPD who have this type of Axis I
comorbidity. However, when the suicide attempt occurs impulsively
as a function of BPD itself, it may be difficult to predict. As in
the case here, careful evaluation of potential interpersonal stress
during times of re-exposure to environments in which suicidal
behavior has previously occurred may be helpful. General guidance
can be obtained from the American Psychiatric Association Practice
Guideline for the Assessment and Treatment of Patients with
Suicidal Behaviors.(15)

Take-Home Points

This case illustrates the following strategies
when treating patients with BPD:

  • Patients with BPD have significantly
    elevated risk of suicide, and suicide attempts and self-injurious
    behavior must be taken seriously, including the use of brief
    hospitalization when necessary.
  • Interpersonal and family relationships
    in patients with BPD are characterized by turbulence and intense
    swings from idealization to devaluation, and the reverse.
  • Active communication among all
    clinicians participating in the treatment of a patient with BPD is
    essential. Hospital staff should make every effort to consult with
    the referring therapist and, preferably, to schedule joint meetings
    during the patient’s inpatient stay.
  • Similarly, active communication with the
    patient’s family and significant other persons in the
    patient’s current life should be pursued.

John M. Oldham, MD
Professor and Chairman, Department of Psychiatry & Behavioral
Sciences
Executive Director, Institute of Psychiatry
Medical University of South Carolina

References

1. Gunderson JG. Borderline Personality Disorder:
A Clinical Guide. Washington DC: American Psychiatric Publishing
Inc; 2001.

2. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders DSM-IV-TR (Text
Revision). 4th ed. Washington, DC: American Psychiatric Publishing;
2000.

3. Torgerson S. Epidemiology. In: Oldham JM,
Skodol AE, Bender DS, eds. American Psychiatric Publishing Textbook
of Personality Disorders. Arlington, VA: American Psychiatric
Publishing Inc; 2005:129–142.

4. Gross R, Olfson M, Gameroff M, et al.
Borderline personality disorder in primary care. Arch Intern Med.
2002;162:53–60.
[go to PubMed]

5. American Psychiatric Association Guidelines.
Practice guideline for the treatment of patients with borderline
personality disorder. American Psychiatric Association. Am J
Psychiatry. 2001;158(suppl 10):1–52.
[go to PubMed]

6. Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen
J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric
states specific to borderline personality disorder. Harv Rev
Psychiatry. 1998;6:201–207.
[go to PubMed]

7. Gunderson JG, Ridolfi ME. Borderline
personality disorder: suicidality and self-mutilation. Ann N Y Acad
Sci. 2001;932:61–73.
[go to PubMed]

8. Stanley B, Brodsky BS. Suicidal and
self-injurious behavior in borderline personality disorder: a
self-regulation model. In: Gunderon JG, Hoffman PD, eds.
Understanding and Treating Borderline Personality Disorder: A Guide
for Professionals and Families. Washington DC: American Psychiatric
Publishing; 2005:43–63.

9. Oldham JM. Borderline personality disorder and
suicidality. Am J Psychiatry. 2006;163:20–26.
[go to PubMed]

10. Black DW, Blum N, Pfohl B, Hale N. Suicidal
behavior in borderline personality disorder: prevalence, risk
factors, prediction, and prevention. J Personal Disord.
2004;18:226–239.
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11. Siever LJ, Torgerson S, Gunderson JG,
Livesley WJ, Kendler KS. The borderline diagnosis III: identifying
endophenotypes for genetic studies. Biol Psychiatry.
2002;51:964–968.
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12. Paris J. Is hospitalization useful for
suicidal patients with borderline personality disorder? J Personal
Disord. 2004;18:240–247.
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13. Osman A, Bagge CL, Guitierrez PM, Konick LC,
Kopper BA, Barrios FX. The Suicidal Behaviors Questionnaire
(SBQ-R): validation with clinical and nonclinical samples.
Assessment. 2001;8:443–454.
[go to PubMed]

14. King R, Lloyd C, Meehan T, O’Neill K,
Wilesmith C. Development and evaluation of the Clinician Suicide
Risk Assessment Checklist. Aust eJournal Adv Ment Health [serial
online]. May 2006;5. Available at: www.auseinet.com/journal/vol5iss1/king.pdf.

15. Practice guideline for the assessment and
treatment of patients with suicidal behaviors. Am J Psychiatry.
2003;160(suppl 11):1–60.
[go to PubMed]

Table

Diagnostic Criteria for Borderline Personality

*Reprinted with permission from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision,
(Copyright 2000). American Psychiatric Association. (2)

A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked impulsivity
beginning by early adulthood and present in a variety of contexts
as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Note:
do not include suicidal or self-mutilating behavior covered in
Criterion 5.
2. A pattern of unstable and intense interpersonal
relationships characterized by alternating between extremes of
idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable
self-image or sense of self.
4. Impulsivity in at least two areas that are potentially
self-damaging (e.g., spending, sex, substance abuse, reckless
driving, binge eating). Note: do not include suicidal or
self-mutilating behavior covered in Criterion 5.
5. Recurrent suicidal behavior, gestures, or threats, or
self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood
(e.g., intense episodic dysphoria, irritability, or anxiety usually
lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger
(e.g., frequent displays of temper, constant anger, recurrent
physical fights).
9. Transient, stress-related paranoid ideation or severe
dissociative symptoms.